ABSTRACT Every 20 minutes in the United States, a newborn is born exposed to opioids. Approximately 50-80% of these newborns will develop Neonatal Opioid Withdrawal Syndrome (NOWS), characterized by autonomic instability, hyperactivity, irritability, tremors, abnormal cry, and difficulty feeding and sleeping. Standard of care dictates that these newborns should be placed on a 96-hour ?hold? in the hospital for observation of NOWS. However, this prolonged hospital stay can lead to both pharmacological and nonpharmacological treatment and even longer hospitalization. For newborns that do develop NOWS, evidence suggests that non-pharmacological interventions could reduce the symptoms of NOWS if intervention is implemented before symptoms of NOWS are detected. The goal of this proposal is to test four novel, noninvasive clinical predictors of NOWS in newborns and as markers of neurodevelopmental impairment at 6 and 18 months: Newborn neurobehavioral assessments, newborn cry, prenatal substance exposure measured via maternal hair, and adverse socioeconomic environments. We correctly identified 86.1% of newborns diagnosed with NOWS using our NNNS and cry data in our pilot studies. If replicated, these findings could lead to personalized treatment regimens and improved care for newborns. The identification of these factors could also provide insights into the pathophysiology and clinical presentation of NOWS. We will conduct longitudinal neurodevelopmental assessments at 6 and 18 months to determine whether these markers predict developmental impairment at these ages. We will also examine whether a diagnosis of NOWS predicts neurodevelopmental impairment at 6 and 18 months. These data will provide clinicians and caregivers with valuable information about the extent to which a NOWS diagnosis portends difficulties in cognitive, motor, or language development in infancy and toddlerhood. We will enroll 312 newborns and their caregivers across two sites: Women and Infants Hospital of Rhode Island and the University of Utah Hospital. Both sites have begun collecting pilot data and have demonstrated success in recruiting 8 newborns/month. The MPIs have an almost 10-year history of collaboration and have published over 20 articles together. In both sites they have established high recruitment and retention rates. The scientific aims of this study are complimented and informed by a carefully designed recruitment and retention plan, and protection of human subjects protocol intended to minimize risk to all participants and provide appropriate resources to caregivers and newborns. When our aims are realized, we will have generated novel and objective predictors of NOWS onset and severity, as well as neurodevelopmental impairment at 6 and 18 months. This longitudinal study will establish a cohort of newborns with prenatal opioid exposure that we plan to retain for long-term neurodevelopmental follow-up into childhood. We also address one of the most pressing societal and health issues of our time, the opioid crisis, to generate data that could lead to reductions in the severity of NOWS.